Georgia Medicaid Book, Chapter 2 – Eligibility Basics

(Last Updated 8/23/2021)

Individuals who are aged (age 65 or older), blind or disabled may be entitled to Medicaid if they are medically eligible and financially needy. In Georgia and Tennessee, SSI recipients are immediately eligible. See 42 U.S.C. § 1396a(a)(10)(A)(i)(II). Although the focus here is on long term care Medicaid, other classes of assistance make Medicaid available to certain special classes such as pregnant women and children needing medical care.

After establishing that one is aged, blind or disabled, there are three elements to Medicaid eligibility: categorical (or technical) eligibility; medical eligibility; and financial eligibility. Categorial and Medical criteria are discussed in this chapter. Financial eligibility is discussed in later chapters. Regardless, for aged, blind and disabled individuals, States may not use requirements more restrictive than those used for SSI. 42 CFR § 435.401(c)(2). See 42 CFR § 435.121 and § 435.230 for exceptions in 209(b) states.

In general, an applicant is entitled to Medicaid if he or she meets all criteria for eligibility during a given month and files an application for Medicaid. Retroactive eligibility is available in most States if the applicant met all eligibility criteria during the three consecutive months immediately preceding the application. Coverage is provided for any full month as long as the applicant meet all eligibility criteria at any time during the month. 42 U.S.C. § 1396a(a)(34). However, as discussed in chapters relating to financial eligibility, for States using the “first moment of the first day of the month” (FOM) rule, if the applicant had countable resources in excess of the resource limit, then eligibility may be denied until the month following spend-down.

Depending on State rules, the effective date of eligibility for benefits is the first day of the month for the month when the application was filed, or the date of application. assuming all of the eligibility requirements are met. In most States, retroactive eligibility is available for up to three months prior to the month of filing if the applicant was eligible during the retroactive months.

A standard of promptness applies when the agency processes Medicaid applications. Unless the applicant applies on the basis of disability, the agency must process the application within 45 days, absent authorized delays, such as the applicant or an examining physician fails to take a required action, or there is an administrative or other emergency beyond the agency’s control. 42 C.F.R. § 435.912(c)(3)(ii). If the applicant applies on the basis of disability, the standard of promptness is 90 days. 42 C.F.R. § 435.912(c)(3)(i).

Georgia and Tennessee are SSI States, which means disability determinations for persons under 65 are made by the Social Security Administration. In Georgia, the Department of Community Health (DCH) is the official Medicaid agency. It contracts with the Department of Family and Children’s Services (DFCS) to provide Medicaid eligibility determinations for clients who do not receive Supplemental Security Income (SSI).” [Note 1]. The Bureau of Tenncare is Tennessee’s Medicaid Agency. T.C.A. § 71-5-102. The Department of Human Services processes Tenncare applications; online applications are handled through Tenncare Connect.

Note 1: The DFCS Manual Chapter 300 described the contractual relationship between DCH and DFCS was at Online applications are handled through the Georgia Gateway.

Note 2: Tenncare – Applying for Services

Categorical Eligibility

The aged, blind, and permanently and totally disabled are categorically eligible for Medicaid. [Note 3]. Medicaid’s definitions of aged, blind and disabled are the same ones used by the Social Security Administration for Social Security and Supplemental Security Income (SSI) benefits:

Aged is defined as as 65 years of age or older. [Note 4]. Medicaid uses the same definition of blind used by the Social Security Administration in determining SSI eligibility. [Note 5]. As in SSI determinations, disability means that an individual is unable to engage in substantial gainful activity because of a medically determinable impairment likely to last twelve months or result in death. [Note 6].

Note 3: 42 C.F.R. § 435.122. This regulation provides that Medicaid must provide coverage to individuals who would be eligible for SSI except for an eligibility requirement not applicable to Medicaid. See also 20 C.F.R. § 416.905 and § 416.906.

Note 4: 42 C.F.R. § 435.520.

Note 5: 42 C.F.R. § 435.530. “An individual shall be considered to be blind for purposes of this subchapter if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes of the first sentence of this subsection as having a central visual acuity of 20/200 or less. An individual shall also be considered to be blind for purposes of this subchapter if he is blind as defined under a State plan approved under subchapter X or XVI of this chapter as in effect for October 1972 and received aid under such plan (on the basis of blindness) for December 1973, so long as he is continuously blind as so defined.” See 42 U.S.C. § 1382c(a)(2).

Note 6: 42 U.S.C. § 1382c(a)(3); 42 C.F.R. § 435.540.

In addition, to establish technical eligibility for nursing home Medicaid, an applicant must be (i) a U.S. Citizen or lawfully admitted alien, (ii) a resident of the State where benefits are sought and (iii) have been treated for a continuous period of 30 days in a medical facility. 42 C.F.R. § 435.211. [Note 7]. By way of example, the technical eligibility criteria and the citations are summarized as follows:

Note 7: Georgia ABD Manual Section 2235, Length of Stay.

Note 8: The following documentation should be sufficient to establish citizenship: birth certificate, U.S. Passport, United States Citizen Identification Card, Report of Birth Abroad of a Citizen of the United States, Certification of Birth issued by a foreign service post. Section 203 of the Immigration and Nationality Act refers to 8 USC § 1153, but subsection (a)(7) no longer exists. 8 USC § 1641 refers to 203 as in effect as of April 1, 1980 in defining qualified aliens.

Note 9: The generic definition of resident is the state where someone is living and intends to reside. 42 C.F.R. § 435.403(h). For purposes of Medicaid, 42 C.F.R. § 435.403(d) expands that definition to include individuals meeting the conditions in paragraphs (e) through (i). Resident also includes adults who are incapable of indicating intent. 42 C.F.R. § 435.403(c).

More on Citizenship

An applicant must be a U.S. Citizen or a legally admitted alien to receive Medicaid. 42 CFR § 435.406. In that regard, HCFA 64 provides as follows:

3210.1 General Requirements.–The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) significantly changed Medicaid eligibility for individuals who are not citizens of the United States. Medicaid must be provided to eligible citizens or nationals of the United States. Individuals who meet the eligibility requirements of Medicaid but are not citizens or nationals of the United States are Medicaid eligible only as provided in §§3211.1 – 3211.10. Those noncitizens described in §§3211.6 – 3211.10 may be eligible to receive treatment for an emergency medical condition as defined in §3211.11 as permitted by the particular section. The documentation and verification requirements in §§3212ff. must also be met.

Submit an amendment to your approved State plan if you make any change in the eligibility of aliens whose coverage is optional, as described in §§3211.5 – 3211.7.

3210.2 United States Citizenship.–For purposes of qualifying as a United States citizen, the United States as defined in the Immigration and Nationality Act includes the 50 States, the District of Columbia, Puerto Rico, Guam, Virgin Islands, and the Northern Mariana Islands. Nationals from American Samoa or Swain’s Island are also regarded as United States citizens for purposes of Medicaid.

3211. ALIENS
Medicaid eligibility for aliens is based on whether the alien is a qualified or non-qualified alien, regardless of whether the alien entered the United States before or on or after August 22, 1996 (the date of enactment of P.L. 104-193). The previous categories of lawful permanent residents and aliens permanently residing in the United States under color of law (PRUCOL) no longer apply. For policies on eligibility for the optional program of presumptive eligibility for pregnant women, see §3570.

3211.1 Qualified Aliens.–A qualified alien is an alien who is:

    • A lawful permanent resident,
    • A refugee (§207 of INA),
    • An asylee (§208 of INA),
    • An alien who has had deportation withheld under §243(h) of the Immigration and Nationality Act (INA),
    • An alien granted parole for at least 1 year by the INS (§21(d)(5) of INA),
    • An alien granted conditional entry under §203(a)(7) of immigration law in effect before April 1, 1980, or
    • A battered immigrant, who meets certain requirements.

This definition eliminates most of the PRUCOL categories as well as PRUCOL as an eligibility classification.

 42 CFR § 435.407  and HFCA 64 list documentation acceptable for proving citizenship.

3212.2 Documentation and Verification of an Applicant’s Citizenship or Alien Status.–Citizens, nationals, and qualified alien applicants for Medicaid must:

A. Provide the State with documentation of citizenship or alien status, and

B. Sign a declaration under penalty of perjury that the applicant is a citizen or national of the United States or an alien in a satisfactory immigration status (henceforth qualified alien) as provided in §3212.1.

All non-citizen applicants for Medicaid who declare they are qualified aliens, must provide Immigration and Naturalization Service (INS) documents to establish immigration status as described in §3212.4. Examples of acceptable documentation for U.S. citizens are given in §3212.3. You must give the alien a reasonable opportunity to provide the required documentation. If the alien does not provide the requested documentation within the State’s reasonable opportunity time frame, you may deny eligibility. If the alien does provide the requested documentation within your reasonable opportunity time frame, verify the documentation with the INS using SAVE or your alternative approved system of verification as provided in §3212.9.

States are required to provide Medicaid eligibility pending verification of immigration status to an individual who meets all other non-immigration Medicaid eligibility requirements, as provided in §1137(d)(4) of the Social Security Act, and who has provided INS documents showing satisfactory immigration status or who has been given a reasonable opportunity to provide such documents to the State.

3212.3 Methods of Documenting United States Citizenship.–The following are examples of acceptable documentation of U.S. citizenship for all Medicaid applicants.

    • Birth certificate,
    • Religious record of birth recorded in the United States or its territories within 3 months of birth, which indicates a U.S. place of birth. The document must show either the date of birth or individual’s age at the time the record was made,
    • United States passport (not limited passports, which are issued for periods of less than 5 years),
    • Report of Birth Abroad of a Citizen of the U.S. (Form FS-240),
    • Certification of Birth (INS Form FS-545),
    • U.S. Citizen I.D. Card (INS Form I-197),
    • Naturalization Certificate (INS Forms N-550 or N-570),
    • Certificate of Citizenship (INS Forms N-560 or N-561),
    • Northern Mariana Identification Card (issued by the INS to a collectively naturalized citizen of the U.S. who was born in the Northern Mariana Islands before November 3, 1986),
    • American Indian Card with a classification code “KIC” and a statement on the back (issued by the INS to identify U.S. citizen members of the Texas Band of Kickapoos living near the U.S./Mexican border), or
    • Contemporaneous hospital record of birth in one of the 50 States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam (on or after April 10, 1899), the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain’s Island, or the Northern Mariana Islands (unless the person was born to foreign diplomats residing in such a jurisdiction).

More on State of Residence

With few exceptions (such as the existence of an interstate compact), a Medicaid applicant must be a resident of the State where benefits are provided. 42 CFR § 435.403. [Note 10]. The “duration” of residence cannot be a condition of eligibility. See 42 CFR § 435.403(j)(1); Shapiro v. Thompson, 394 U.S. 618 (1969). HCFA 64 provides the following guidance in determining the State of residence for those who are 21 and older:

3230.2 Residence Criteria Specific To Individuals Age 21 and Over.–

A. Determining State Residence for an Individual Not Residing in an Institution.–The State of residence is the State where the individual is living with the intention to remain there permanently or for an indefinite period, or where the individual is living and which he/she entered with a job commitment, or seeking employment whether or not currently employed.

B. Institutionalized Individuals Who Became Incapable of Indicating Intent Before Age 21.–For an individual who became incapable of indicating intent before age 21, use one of the following to determine the State of residence except when a State places the individual in an institution. (See §§3230.C and 3230.3B.)

    • If a legal guardian is appointed and parental rights are terminated, the State of residence of the guardian is used instead of the parent(s).
    • The parents’ or legal guardian’s current State of residence at the time of placement. In determining the parent(s’) or guardian’s State of residence, apply the same rules for determining residence for an applicant or recipient over 21 and noninstitutionalized (See §3230(D)(1).

C. Determining State of Residence for an Institutionalized Individual Who Became Incapable of Indicating Intent at or after Age 21. –The State of residence is the State where the individual is physically present, except where another State makes a placement. ( See §§3230.D and 3230.3B.)

D. Determining State of Residence for an Institutionalized Individual Capable of Indicating Intent.–The State of residence is the State where the individual is living with the intention to remain there permanently or for an indefinite period.

Note 10: When two or more States cannot resolve which State is the State of residence, the State where the individual is physically located is the State of residence for Medicaid purposes. HCFA 64, § 3230.6.

Tennessee and Georgia have entered into an interstate agreement providing that residents from either State may receive benefits in the other without establishing residency. [Note 11]. HCFA 64 addresses those agreements as follows:

3230.4 Interstate Agreements.–States and Territories are permitted to enter into a written agreement with another State to resolve cases of disputed residence. You may establish criteria other than the criteria set forth defining ” who is a State resident” at 42 CFR 435.403(d), and 436.403(d). Do not include criteria that are prohibited, as specified in §3230.3, or that result in loss of residency in both States. The agreement must also contain a procedure for providing Medicaid to individuals pending resolution of the case.
The regulations established the provision for interstate agreements to deal with cases of disputed residence, and allows you to expand the use of such agreements for reasons other than cases specifically related to disputed residence.

You may use interstate agreements to facilitate the placement and adoption of title IV-E individuals when the child and his/her adoptive parent(s) move into another State. However, you may not use interstate agreements to override the provisions added to §1902(a) of the Act by §9529 of COBRA.

If you enter into interstate compacts as provided for under P.L. 96-272, you may establish reciprocal agreements for providing medical assistance for individuals receiving adoption assistance payments.

An agreement may be very limited or very broad at your option, e.g., an agreement can pertain to one individual, all institutionalized individuals, or all individuals.

Note 11: 42 CFR § 435.403(k).

Medical Eligibility

Only those persons with a medical need are eligible for Medicaid and not all persons needing help receive Medicaid. In Georgia, medical eligibility determinations for nursing home facility care are performed by the facility using Form DMA-59. Determinations for CCSP (HCBS) are made by the CCSP RN Care coordinator.

As part of the technical criteria, long-term care Medicaid usually includes a length of stay requirement and long-term care COAs typically require nursing facility level care. A nursing home resident must be confined to an institution for 30 days or more to establish eligibility. [Note 12]

Note 12: 42 U.S.C. § 1396a(a)(10)(A)(ii)(V).

Separate from the technical criteria, each State is responsible for the administration and enforcement of Pre-screening and Annual Resident Reviews (PASRR). [Note 13]. The purpose of the PASRR is to determine whether institutional placement (if applicable) is medically appropriate. [Note 14]. While medical eligibility is evaluated for each class of assistance [Note 15], here we limit the inquiry to long-term care Medicaid. The inquiry would be different, for example, in the context of a Katie Beckett waiver.

Note 13: 42 C.F.R. § 483.104. See 42 CFR Subpart C – Preadmission Screening and Annual Review of Mentally Ill and Mentally Retarded Individuals.

Note 14: 42 U.S.C. § 1396r(e)(7). Although the PASRR requirement pre-dates Olmstead v. L.C. by 10 years, it is consistent with the holding that mentally ill individuals should not be institutionalized for convenience. There must be a medical need.

Note 15: See, e.g., Georgia Medicaid Manual § 2101 (overview of various classes of assistance).

An applicant must demonstrate that he or she meets the medical criteria for Medicaid eligibility. A separate application form, called a “Pre-Admission Evaluation” must be completed and sent to Medicaid for processing and approval. [Note 16]. For discussion purposes, we address the Tennessee rules, although the criteria and procedure are similar in Georgia.

Note 16: In Georgia, the form is a DMA-59. State definitions of medical necessity for EPSDT benefits are listed at the National Academy for State Health Policy website.

The PAE needs to be approved within 90 days of the person’s admission to the nursing facility. Tenn. Comp. Rules and Regs Rule 1200-13-1-.10(2)(e) (May 2021). The individual must also undergo a Pre-Admission Screening and Annual Resident Review (PASRR) Level 1 assessment by the Tennessee Department of Mental Health and Mental Retardation to determine if there is a need for mental health services that can only be provided in a long term care setting. Tenn. Comp. Rules and Regs. Rule 1200-13-1-.10(2)(h) (Oct. 2003); Smith v. Chattanooga Medical Investors, Inc., 62 S.W.3d 178 (Tenn. App. 2001). [Note 17].

Note 17: In Georgia, the Department of Community Health is the Medicaid agency, but DCH has contracted with the Department of Family and Children Services to make eligibility determinations. See O.C.G.A. § 31-2-4 and O.C.G.A. § 49-4-142.

To demonstrate medical eligibility for nursing home care, the applicant must need long term nursing home care. In Tennessee, there are three levels of care: CHOICES Groups 1, 2 and 3. Choices 1 is limited to Tenncare members who qualify for and are receiving Tenncare reimbursed nursing facility services. Choices 2 and 3 are limited to Tenncare members receiving Choices HCBS. Tenn. Comp. Rules and Regs Rules 1200-13-1-.05(3). See also Tenn. Comp. Rules and Regs Rules 1200-13-1-.10(4) through (6) (May 2021). [Note 18].

Note 18: Medicare will pay for 100% of days 1 through 20 if the necessity for skilled care continues following a qualifying hospital stay. If additional skilled care is necessary, then after the nursing home resident pays the daily co-pay (in 2021, $185.50), Medicare pays the balance. Some Medi-gap policies provide coverage for the daily co-pay. It should be noted, however, that Medicare days are not guaranteed; if skilled care is no longer necessary, Medicare coverage terminates.

Applicants must have a physical or mental condition, disability, or impairment that, as a practical matter, requires daily inpatient nursing care. The Applicant must be unable to self-perform needed nursing care and must meet one (1) or more of the following criteria on an ongoing basis. Tenn. Comp. Rules and Regs. Rule 1200-13-1-.10(4). See also Georgia ABD Manual section 2240.

These conditions are expected to be continual and ongoing, and not a matter of an isolated lapse or exceptional occurrence. See Jaco v. Department of Health, Bureau of Tenncare, 1999 WL 346241 (Tenn. App. 1999).

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